procedure codes 11400-11446 should be used when the excision is a full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure.

Claims for removal of benign skin lesions performed merely for cosmetic reasons may not necessarily need to be submitted to Medicare unless the patient requests that a formal Medicare denial is issued. If a claim is filed, ICD-9 CM code V50.1 (Other plastic surgery for unacceptable cosmetic appearance) should be used in conjunction with the appropriate procedure code

If a dermatologist performs an excision (11400) with benign lesion destruction (17110), both codes are reportable and a modifier will be necessary to “bypass” the edit. 11400 is mutually exclusive to the 17110 which documentation of both procedures will support reporting both codes with the appropriate modifier. According to CMS, there must be a NCCI procedure to procedure (PTP) edits, which in this case there is, to require a modifier. Otherwise it is not needed.Col 1 Col 2 Effect Date Allowance

Benign skin lesions are common in the elderly and are frequently removed at the patient’s request to improve appearance. Removal of benign skin lesions that do not pose a threat to health or function is considered cosmetic and as such is not covered by the Medicare program. Cosmesis is statutorily non-covered and no payment may be made for such lesion removal.

Medicare will consider the removal of benign skin lesions as medically necessary, and not cosmetic, if one or more of the following conditions is present and clearly documented in the medical record:

A. The lesion has one or more of the following characteristics:
1. bleeding
2. intense itching
3. pain

D. The clinical diagnosis is uncertain, particularly where malignancy is a realistic consideration based on lesional appearance (e.g. non-response to conventional treatment, or change in appearance). However, if the diagnosis is uncertain, either biopsy or removal may be more prudent than destruction.

E. A prior biopsy suggests or is indicative of lesion malignancy or premalignancy.

F. The lesion is in an anatomical region subject to recurrent physical trauma and there is documentation that such trauma has in fact occurred.

G. Wart removals will be covered under (a) through (f) above. In addition, wart destruction will be covered when the following clinical circumstance is present:

Evidence of spread from one body area to another, particularly in immunocompromised/immunosuppressed patients.

Note:
1) CPT codes 17106, 17107 and 17108 describe treatment of lesions that are usually cosmetic. When using these CPT codes the clinical records should clearly document the medical necessity of such treatment and why the procedure is not cosmetic.

2) CPT codes 11055, 11056 and 11057 describe treatment of hyperkeratotic lesions (e.g., corns and calluses). Coverage for these three codes is described in the Medicare Internet Only Manual.

If the beneficiary wishes one or more benign asymptomatic lesions removed for cosmetic purposes, the beneficiary becomes liable for the service(s) rendered.Regarding other Malignancy:
If a diagnosis of malignancy has already been established for a specific lesion, a shave biopsy would not be medically reasonable and necessary.

When a diagnosis of malignancy has not yet been established at the time the biopsy procedure was performed, the correct diagnosis code to list on the claim would most likely be D49.2, (Neoplasm of unspecified behavior, bone soft tissue, and skin).

Compliance with the provisions in this policy may be subject to monitoring by post payment data analysis and subsequent medical review.

Documentations Requirements

The medical record must be made available to Medicare upon request.

The HCPCS/procedure code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

When, the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary.

When requesting a written redetermination (formerly appeal), please send all relevant documentation with the request.

Benign skin lesion removals for reasons other than those given under the Indications andLimitations of Coverage and or Medical Necessity Section above are considered to be cosmetic and will not be covered. These noncovered reasons include, but are not limited to, emotional distress, “makeup trapping” and non-problematic lesions in any anatomic location.

Medical documentation must clearly and unequivocally document the medical necessity for lesion removal(s) if Medicare is billed for the service.

A medical record statement of “irritated skin lesion” is insufficient justification for lesion removal when solely used to reference a patient’s complaint or a physician’s physical findings. Similarly, use of ICD-9-CM 702.11, inflamed seborrheic keratosis, is insufficient to justify lesional removal without medical documentation of the patient’s symptoms and physical findings.

Medicare will not pay for a separate E/M service on the same day dermatologic surgery is performed unless significant and separately identifiable medical services were rendered and clearly documented in the patient’s medical record. Append modifier 25 to the appropriate visit code to indicate the patient’s condition required a significant, separately identifiable visit service unrelated to the procedure that was performed.

Office visits will be covered when the diagnosis of a benign skin lesion(s) is made even if the removal of a particular lesion or lesion(s) is not medically indicated and is therefore not done.

Lesions in sensitive anatomic locations that are non-problematic do not qualify for removal coverage on the basis of location alone.

The type of removal is at the discretion of the treating physician and the appropriateness of the technique used will not be a factor in deciding if a lesion merits removal. However, a benign lesional excision (procedure 11400-11446) must have medical record documentation as to why an excisional removal, other than for cosmetic purposes, was the surgical procedure of choice. This means the medical record for a benign lesion excision (procedure 11400-11446) must show why an excisional removal was the procedure of choice.

The decision to submit a specimen for pathologic interpretation will be independent of the decision to remove or not remove the lesion. It is assumed, however, that a tissue diagnosis will be part of the medical record when an ultimately benign lesion is removed based on physician uncertainty as to the final clinical diagnosis.How should CPT or HCPCS codes such as 11400 (excision of benign lesion) be billed when they are performed on both sides of the body and are not CMS bilateral eligible?

A: An excision of a lesion is not truly bilateral. It should be billed with units, rather than the bilateral modifier.

Benign skin lesions are common in the elderly and are frequently removed at the patient's request to improve appearance. Removals of certain benign skin lesions that do not pose a threat to health or function are considered cosmetic, and as such, are not covered by the Medicare program. These cosmetic reasons include, but are not limited to, emotional distress, "makeup trapping," and non-problematic lesions in any anatomic location. Lesions in sensitive anatomical locations that are not creating problems do not qualify for removal coverage on the basis of location alone.

Medicare covers the destruction of actinic keratoses without restrictions based on lesion or patient characteristics.

Indications:

There may be instances in which the removal of benign seborrheic keratoses, sebaceous cysts, skin tags, moles (nevi), acquired hyperkeratosis (keratoderma), molluscum contagiosum, milia and viral warts is medically appropriate. Medicare will, therefore, consider their removal as medically necessary, and not cosmetic, if one or more of the following conditions are presented and clearly documented in the medical record:

Bleeding;
Intense itching;
Pain;
Change in physical appearance (reddening or pigmentary change);
Recent enlargement;
Increase in the number of lesions;
Physical evidence of inflammation or infection, e.g., purulence, oozing, edema, erythema, etc.;
Lesion obstructs an orifice;
Lesion clinically restricts eye function. For example:
Lesion restricts eyelid function;
lesion causes misdirection of eyelashes or eyelid;
lesion restricts lacrimal puncta and interferes with tear flow;
lesion touches globe;
Clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on lesion appearance;
A prior biopsy suggests or is indicative of lesion malignancy;
The lesion is in an anatomical region subject to recurrent physical trauma, and there is documentation that such trauma has, in fact, occurred;
Recent enlargement, history of rupture or previous inflammation, or location subjects patient to risk of rupture of epidermal inclusion (sebaceous) cyst.
Wart removals will be covered under the guidelines above. In addition, wart destruction will be covered when any of the following clinical circumstances are present:
Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesion virus shedding;
Warts showing evidence of spread from one body area to another, particularly in immunosuppressed patients or warts of recent origin in an immunocompromised patients;
Lesions are condyloma acuminata or molluscum contagiosum;
Cervical dysplasia or pregnancy is associated with genital warts.
Limitations:

Medicare will not pay for a separate E & M service on the same day as a minor surgical procedure unless a documented significant and separately identifiable medical service is rendered. The service must be fully and clearly documented in the patient’s medical record and a modifier 25 should be used.

Medicare will not pay for a separate E & M service by the operating physician during the global period unless the service is for a medical problem unrelated to the surgical procedure. The service must be fully and clearly documented in the patient’s medical record.

If the beneficiary wishes one or more of these benign asymptomatic lesions removed for cosmetic purposes, the beneficiary becomes liable for the service rendered. The physician has the responsibility to notify the patient in advance that Medicare will not cover cosmetic dermatological surgery and that the beneficiary will be liable for the cost of the service. It is strongly advised that the beneficiary, by his or her signature, accept responsibility for payment. Charges should be clearly stated as well.

The type of removal is at the discretion of the treating physician and the appropriateness of the technique used will not be a factor in deciding if a lesion merits removal. However, a benign lesion excision (CPT 11400-11446) must have medical record documentation as to why an excisional removal, other than for cosmetic purposes, was the surgical procedure of choice. Excision is defined as full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed. Each benign lesion excised should be reported separately. Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter). The margins refer to the most narrow margin required to adequately excise the lesion, based on the physician's judgment. The measurement of lesion plus margin is made prior to excision.

D23.71Other benign neoplasm of skin of right lower limb, including hip

D23.72Other benign neoplasm of skin of left lower limb, including hip

D23.9Other benign neoplasm of skin, unspecified

D28.0Benign neoplasm of vulva

D29.0Benign neoplasm of penis

D29.4Benign neoplasm of scrotum

D86.3Sarcoidosis of skin

D86.89Sarcoidosis of other sites

D86.9Sarcoidosis, unspecified

I78.1Nevus, non-neoplastic

K64.4Residual hemorrhoidal skin tags

L12.30Acquired epidermolysis bullosa, unspecified

L12.31Epidermolysis bullosa due to drug

L12.8Other pemphigoid

L72.0Epidermal cyst

L72.11Pilar cyst

L72.12Trichodermal cyst

L72.2Steatocystoma multiplex

L72.3Sebaceous cyst

L72.8Other follicular cysts of the skin and subcutaneous tissue

L82.1Other seborrheic keratosis

L85.9Epidermal thickening, unspecified

L87.9Transepidermal elimination disorder, unspecified

L90.5Scar conditions and fibrosis of skin

L90.9Atrophic disorder of skin, unspecified

L91.0Hypertrophic scar

L91.8Other hypertrophic disorders of the skin

L91.9Hypertrophic disorder of the skin, unspecified

L94.9Localized connective tissue disorder, unspecified

Q17.0Accessory auricle

Q81.0Epidermolysis bullosa simplex

Q81.1Epidermolysis bullosa letalis

Q81.2Epidermolysis bullosa dystrophica

Q81.8Other epidermolysis bullosa

Q81.9Epidermolysis bullosa, unspecified

Q82.8Other specified congenital malformations of skin

B78.1Cutaneous strongyloidiasis

D48.5Neoplasm of uncertain behavior of skin

D49.2Neoplasm of unspecified behavior of bone, soft tissue, and skin

E83.2Disorders of zinc metabolism

K12.2Cellulitis and abscess of mouth

L02.01Cutaneous abscess of face

L02.11Cutaneous abscess of neck

L02.211Cutaneous abscess of abdominal wall

L02.212Cutaneous abscess of back [any part, except buttock]

L02.213Cutaneous abscess of chest wall

L02.214Cutaneous abscess of groin

L02.215Cutaneous abscess of perineum

L02.216Cutaneous abscess of umbilicus

L02.31Cutaneous abscess of buttock

L02.411Cutaneous abscess of right axilla

L02.412Cutaneous abscess of left axilla

L02.413Cutaneous abscess of right upper limb

L02.414Cutaneous abscess of left upper limb

L02.415Cutaneous abscess of right lower limb

L02.416Cutaneous abscess of left lower limb

L02.511Cutaneous abscess of right hand

L02.512Cutaneous abscess of left hand

L02.611Cutaneous abscess of right foot

L02.612Cutaneous abscess of left foot

L02.811Cutaneous abscess of head [any part, except face]

L02.818Cutaneous abscess of other sites

L03.111Cellulitis of right axilla

L03.112Cellulitis of left axilla

L03.113Cellulitis of right upper limb

L03.114Cellulitis of left upper limb

L03.115Cellulitis of right lower limb

L03.116Cellulitis of left lower limb

L03.121Acute lymphangitis of right axilla

L03.122Acute lymphangitis of left axilla

L03.123Acute lymphangitis of right upper limb

L03.124Acute lymphangitis of left upper limb

L03.125Acute lymphangitis of right lower limb

L03.126Acute lymphangitis of left lower limb

L03.211Cellulitis of face

L03.212Acute lymphangitis of face

L03.221Cellulitis of neck

L03.222Acute lymphangitis of neck

L03.311Cellulitis of abdominal wall

L03.312Cellulitis of back [any part except buttock]

L03.313Cellulitis of chest wall

L03.314Cellulitis of groin

L03.315Cellulitis of perineum

L03.316Cellulitis of umbilicus

L03.317Cellulitis of buttock

L03.321Acute lymphangitis of abdominal wall

L03.322Acute lymphangitis of back [any part except buttock]

L03.323Acute lymphangitis of chest wall

L03.324Acute lymphangitis of groin

L03.325Acute lymphangitis of perineum

L03.326Acute lymphangitis of umbilicus

L03.327Acute lymphangitis of buttock

L03.811Cellulitis of head [any part, except face]

L03.818Cellulitis of other sites

L03.891Acute lymphangitis of head [any part, except face]

L03.898Acute lymphangitis of other sites

L08.82Omphalitis not of newborn

L08.89Other specified local infections of the skin and subcutaneous tissue

L08.9Local infection of the skin and subcutaneous tissue, unspecified

L26Exfoliative dermatitis

L29.9Pruritus, unspecified

L30.4Erythema intertrigo

L53.8Other specified erythematous conditions

L53.9Erythematous condition, unspecified

L54Erythema in diseases classified elsewhere

L92.0Granuloma annulare

L95.1Erythema elevatum diutinum

L98.2Febrile neutrophilic dermatosis [Sweet]

L98.3Eosinophilic cellulitis [Wells]

R20.0Anesthesia of skin

R20.1Hypoesthesia of skin

R20.2Paresthesia of skin

R20.3Hyperesthesia

R20.8Other disturbances of skin sensation

R58Hemorrhage, not elsewhere classified

Medical Indications

There may be instances in which the removal of non-malignant skin lesions is medically appropriate. Medicare will, therefore, consider their removal as medically necessary and not cosmetic, if one or more of the following conditions are present and clearly documented in the medical record:
The lesion has one or more of the following characteristics: bleeding, itching, pain; change in physical appearance (reddening or pigmentary change), recent enlargement, increase in number; or

The lesion has physical evidence of inflammation, e.g., purulence, edema, erythema; or

The lesion obstructs an orifice; or

The lesion clinically restricts vision; or

There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on the lesion appearance; or

A prior biopsy suggests or is indicative of lesion malignancy; or

The lesion is in an anatomical region subject to recurrent trauma, and there is documentation of such trauma.

Wart removals will be covered under the guidelines listed above. In addition, wart destruction will be covered when any one of the following clinical circumstances is present:
Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesion virus shedding.

Warts showing evidence of spread from one body area to another, particularly in immunosuppressed patients.

Lesions are condyloma acuminata or molluscum contagiosum.

Cervical dysplasia or pregnancy is associated with genital warts.

An E&M service to determine a diagnosis of benign skin lesion(s) may be allowed (paid), even in the event the subsequent lesion(s) removal is determined to be cosmetic.

Repair (Closure) With Excision of Benign Lesions
Payment for the excision of benign lesions of skin includes payment for simple repairs. Separate payment may be made for medically necessary layered closures, adjacent tissue transfers, flaps and grafts.

Limitations:

Medicare will not pay for a separate E & M service on the same day as a dermatologic service unless a documented significant and separately identifiable medical service is rendered. The service must be fully and clearly documented in the patient’s medical record and a modifier 25 should be used.

Medicare will not pay for a separate E & M service by the operating physician during the global period unless the service is for a medical problem unrelated to the surgical procedure. The service must be fully and clearly documented in the patient’s medical record.

If the beneficiary wishes one or more of these benign asymptomatic lesions removed for cosmetic purposes, the beneficiary becomes liable for the service rendered. The physician has the responsibility to notify the patient in advance that Medicare will not cover cosmetic dermatological surgery and that the beneficiary will be liable for the cost of the service. It is strongly advised that the beneficiary, by his or her signature, accept responsibility for payment. Charges should be clearly stated as well.

The type of removal is at the discretion of the treating physician and the appropriateness of the technique used will not be a factor in deciding if a lesion merits removal. However, a benign lesion excision must have medical record documentation as to why an excisional removal, other than for cosmetic purposes, was the surgical procedure of choice.

Excision is defined as full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed. Each benign lesion excised should be reported separately. Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter). The margins refer to the narrowest margin required to adequately excise the lesion, based on the physician's judgment. The measurement of lesion plus margin is made prior to excision.

References to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants.

AMA

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